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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604176
Report Date: 10/09/2024
Date Signed: 10/09/2024 02:51:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/03/2024 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241003120638
FACILITY NAME:ALTA VISTA SENIOR LIVINGFACILITY NUMBER:
374604176
ADMINISTRATOR:ALSPACH, DAVIDFACILITY TYPE:
740
ADDRESS:2041 W VISTA WAYTELEPHONE:
(760) 941-3233
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:98CENSUS: 80DATE:
10/09/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennifer Gephart, Executive Director TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure the facility elevator is in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegations listed above. LPA met with Jennifer Gephart, Executive Director and explained the purpose of the visit and the elements of the allegations. The allegation was investigated, and the investigation consisted of observations interviews and records review. On 10/03/2024 Community Care Licensing received a complaint alleging that Staff did not ensure the facility elevator is in good repair.

LPA conducted an interview with Business Office Manager Monica Flores that revealed that one of the facility elevators was recently in operable due to it being retagged by the state. Per Monica there are inspections conducted on a monthly basis. During a recent inspection it was discovered that the outlet and light/lamp fixtures were identified as not operable. LPA conducted a records review which revealed that the facility was informed 1 year ago that the elevator mdoel required a new outlet and light fixture, while another part was being installed. As a result the elevator was red tagged and was prohibited from being used. Based on records review the allegation of staff did not ensure the elevator is in good repair is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20241003120638
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176
VISIT DATE: 10/09/2024
NARRATIVE
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A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Note that during today's visit LPA verified that the elevator is in working order. The elevator was observed to be fully illuminated and there was no signs observed prohibiting use of the elevator.

An exit interview was conducted and a copy of this report, 9099D, and appeal rights were provided to Jennifer Gephart, Executive Director.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20241003120638
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/09/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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There is no POC at this time, as the elevator was officially repaired on 09/13/24.
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 the licensee did not ensure that the elevator was in good repair, which posed a potential health, safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3